In-network coverage denied at MD Anderson for those on individual health insurance plans

December 1, 2016 by Ali D.

Cancer. It’s one of those things that brings life into focus, reminding us that each day is treasured. A recent health insurance update from leading cancer center, MD Anderson, just made the diagnosis even harder to grasp.

Individuals and families who don’t get insurance through their employers are bumping up against harsh realities this year as they search the marketplace for individual plans. While this presents a hassle and expense for most people, this is a much more serious matter for those battling cancer. For those who are fighting for their life, being denied coverage to state-of-the-art care at MD Anderson is a life or death matter.

MD Anderson, the cornerstone treatment facility for cancer care nationwide, is not as accessible as it once was due to the shifting nature of the insurance marketplace. In fact, we reached out to MD Anderson to ask which plans they accept from the individual marketplace. Their response? None. That means if you are seeking treatment at MD Anderson and are simultaneously enrolling in individual health insurance, you will be forced to pay out of network expenses at MD Anderson.

Why is this happening?

MD Anderson is only accepting plans that pay the most. And insurance carriers are not stepping up and paying more. The result? The individual consumer, aka the cancer fighter, gets the short end of the stick.

Cancer by the numbers

Cancer affects more than 20 million Americans each year. Apart from shifting your life’s mission to survival, cancer also comes with a hefty financial price tag. Cancer costs vary depending upon the type of cancer and treatment plan. Patients spend the most money on surgeries, medications (like chemotherapy) and radiation treatments. A 2014 study found that the average cost of a cancer-related surgery was $35,000. 12 months of chemotherapy can cost up to $100,000 and three months of radiation therapy could be $35,000. So, the average cancer patient might start off facing $170,000 of health-related costs. That doesn’t even factor in the cost of time off work, childcare, unexpected hospital admissions and medications.

You’ve got options.

Take Command Health wants to help you find the least expensive ways to access care at MD Anderson. If you are searching the individual marketplace, your best bet is to elect for an individual plan that has some out of network benefits.

After doing some digging, here is what we found for coverage in Texas. Take Command Health also helps clients in Arizona, Georgia, Florida, Michigan and Wisconsin. Live in one of those states and seeking cancer treatment at MD Anderson? We can help!

*Premiums vary, this data is based upon a 40 year old non smoking male.

Dallas, Texas

Baylor Scott and White PPO Bronze Plan

Preferred Provider Organization (PPO): you don’t need a referral to see a specialist.

Premium: $430/month

Deductible: Out of network for individual $14,300 and $28,000 for a family.

Out of Network Max: The most you will pay out of pocket per calendar year when you receive treatment at MD Anderson is $14,300 per individual and $28,000 for a family. Once you reach this price point, all services will be covered at 100%.

What does this mean for your $170, 000 bill? You pay $14,300 deductible plus $5,100 per year for your premium. Your savings: 88%.

Houston, Texas

Memorial Hermann Elect Silver Plan PPO

Preferred Provider Organization (PPO): you don’t need a referral to see a specialist.

Premium: $520/month

Deductible Out of Network: $8,000/individual, $16,000/family. Once you fulfill your out of network deductible, you are responsible for 50% of specialist’s visits.

Out of Network Out of Pocket Max: The most you will have to pay out of pocket for out of network providers: $15,000 as an individual and $30,000 for a family.

What does this mean for your $170,000 bill? You pay $8,000, then 50% of all visits until you’ve paid $15,000. You also pay $6,200 premium. Total savings: 87%.

Memorial Hermann Elect Silver HSA

Preferred Provider Organization (PPO): you don’t need a referral to see a specialist.

Premium: $520/month

HSA Benefit: Contribute money to your health savings account tax-free. This saves you the tax on all money you contribute to your HSA. Under 55 years old: max of $3,350 and $6,750 for family. Over 55: can add $1,000 more.

Deductible: Out of network provider (MD Anderson): $5,000/individual $10,000/family. Once you reach deductible, specialist’s visits are covered at 50%.

Out of Network Max: The most you have to pay out of pocket for an out of network provider is $15,000 per individual and $30,000 per family.

Medications: From out of network providers, mediations are covered at 50%. Because many cancer medications are specialty drugs, your doctor is often required to make a call or fill out extra paper work in the form of a prior authorization.

What does this mean for your $170,000 bill? You pay $5,000 up front, then 50% of your bills until you reach $15,000. Add in $6,200 for your premium. Subtract your HSA savings, roughly $1,000. You save: 88%.

Statewide in Texas

Blue Cross HMO plus and Multi-state plans

HMO plans require a referral to see a specialist.

Premium: $540/month

Deductible: No out of network deductible.

Out of Network Max: No maximum. You just keep paying.

What is covered? 50% of all services are covered.

What does this mean for your $170,000 bill? You will pay $85,000 plus $6,400 premium. Total savings: 46%.

Out of Network Benefits Summary

Insurance

Deductible

Out of Pocket Max

Medications

Savings

Baylor Scott & White PPO

$14,300 individual

$28,600 family

$14,300 individual

$28,600 family

50% after deductible

88%

Memorial Hermann PPO

$8,000 individual

$16,000 family

$15,000 individual

$30,000 family

50% after deductible

87%

Memorial Hermann HSA

$5,000 individual

$10,000 family

$15,000 individual

$30,000 family

50% after deductible

88%

BCBS HMO

$15,000 individual

$45,000 family

Unlimited

50% coinsurance

46%

What’s the Bottom Line?

If you are an MD Anderson patient and shopping the individual marketplace, your best bet is to enroll in a plan that can help keep your costs as low as possible. Currently there are no individual plans offered that provide in-network coverage with MD Anderson. Electing a plan that has an out of pocket maximum puts a limit on how much you will have to spend this year. Even if that out of pocket maximum is $15,000 that sure beats the $170,000 you would be charged without any coverage.

Take Command Health is here to help.

You have enough on your plate battling cancer. We want to help you find the best plan for your unique situation. Email us at support@takecommandhealth.com or sign up below to learn more about the best insurance options to help you continue treatment at MD Anderson.

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Hi, I'm Ali D.! Family Nurse Practitioner and mother of twins, I am passionate about helping people gain access to great health care. After studying at Davidson College and Georgia State University, I began to see the problem of health disparities and insurance frustrations by working at both a cardiology practice and community health clinic. Now, as a 3rd generation primary care provider, I'm hoping to continue the legacy of easing access to affordable health care and promoting healthy living.
In my free time you can find me chasing the kids at a park or embarrassing myself at a new exercise class at the YMCA. Don't get too close, you might just find remnants of the twin's breakfast on my shirt!

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